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Davis TA, Gyawali CP. Refractory Gastroesophageal Reflux Disease: Diagnosis and Management. J Neurogastroenterol Motil 2024; 30:17-28. [PMID: 38173155 PMCID: PMC10774805 DOI: 10.5056/jnm23145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/16/2023] [Indexed: 01/05/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.
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Affiliation(s)
- Trevor A Davis
- Division of Pediatric Gastroenterology, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Rodier S, Henning J, Kukreja J, Mohammedi T, Shah P, Damani T. Robotic Primary and Revisional Hiatal Hernia Repair is Safe and Associated with Favorable Perioperative Outcomes: A Single Institution Experience. J Laparoendosc Adv Surg Tech A 2023; 33:932-936. [PMID: 37417969 DOI: 10.1089/lap.2023.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Background: Robotic hiatal hernia (HH) repair has been demonstrated to be feasible and safe. Recent conflicting reports have emerged on the higher incidence of perioperative complications with robotic HH repair when compared with laparoscopic repair. Materials and Methods: A retrospective review of a prospective database at an academic medical center for all robotic HH repairs performed by a high-volume foregut surgeon from 2018 to 2021 was performed. Outcome measures included operative time, estimated blood loss (EBL), length of stay (LOS), conversion rate, need for esophageal lengthening procedure, intra- and perioperative complications, and 30-day in-hospital mortality. Results: One hundred four patients were included in the analysis. Fifteen percent of patients had a type I HH, 2% had a type II, 73% had a type III, and 10% had a type IV HH. Eighty-four percent of cases were primary and 16% were revisional. Fifty-four percent of patients had mesh placed and 4.4% had an esophageal lengthening procedure. Mean EBL was 15 mL and mean operative time was 151 minutes. Median LOS was 2 days (interquartile range 1-2 days). There were zero conversions. Intraoperative complication rate was 1% and 30-day complication rate was 4%. The 30-day in-hospital mortality was zero. Conclusion: In this retrospective analysis of 114 consecutive robotic HH repairs performed, with 83% type III or IV HHs and 16% revisional hiatal cases, our results demonstrate favorable perioperative outcomes, with lower EBL, shorter LOS, lower complication rate, zero conversions, and comparable operative times compared with historical laparoscopic data.
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Affiliation(s)
- Simon Rodier
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Justin Henning
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Janvi Kukreja
- Division of the Biological Sciences, University of Chicago, Chicago, Illinois, USA
| | - Taher Mohammedi
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Paresh Shah
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Tanuja Damani
- Department of Surgery, NYU Langone Health, New York, New York, USA
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Mackey EE, Dore FJ, Kelly JF, Crawford AS, Cohen P, Czerniach D, Perugini R, Kelly JJ, Cherng NB. Ligamentum teres cardiopexy for post vertical sleeve gastrectomy gastroesophageal reflux. Surg Endosc 2023; 37:7247-7253. [PMID: 37407712 DOI: 10.1007/s00464-023-10239-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/11/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Vertical sleeve gastrectomy (VSG) evolved in the early 2000s into the standalone weight loss procedure we see today. While numerous studies highlight VSG's durability for weight loss, and improvements co-morbidities such as type 2 diabetes mellitus and cardiovascular disease, patients with gastroesophageal reflux disease (GERD) have been counseled against VSG due to the concern for worsening reflux symptoms. When considering anti-reflux procedures, VSG patients are unable to undergo traditional fundoplication due to lack of gastric cardia redundancy. Magnetic sphincter augmentation lacks long-term safety data and endoscopic approaches have undetermined longitudinal benefits. Until recently, the only option for patients with a history of VSG with medically refractory GERD has been conversion to roux en Y gastric bypass (RNYGB), however, this poses other risks including marginal ulcers, internal hernias, hypoglycemia, dumping syndrome, and nutritional deficiencies. Given the risks associated with conversion to RNYGB, we have adopted the ligamentum teres cardiopexy as an option for patients with intractable GERD following VSG. METHODS A retrospective chart review was conducted of patients who had prior laparoscopic or robotic VSG and subsequently GERD symptoms refectory to pharmacological management who underwent ligamentum teres cardiopexy between 2017 and 2022. Pre-operative GERD disease burden, intraoperative cardiopexy characteristics, post-operative GERD symptomatology and changes in H2 blocker or PPI requirements were reviewed. RESULTS Of the study's 60 patients the median age was 50 years old, and 86% were female. All patients had a diagnosis of GERD through pre-operative assessments and were taking antisecretory medication. Of the 36 patients who have completed their one year follow up, 81% of patients had either a decrease in dosage or cessation of the antisecretory medication at one year following ligamentum teres cardiopexy. CONCLUSION Ligamentum teres cardiopexy is a viable alternative to RNYGB in patients with a prior vertical sleeve gastrectomy with medical refractory GERD.
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Affiliation(s)
- Emily E Mackey
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Fiona J Dore
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John F Kelly
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Allison S Crawford
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Philip Cohen
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Donald Czerniach
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Richard Perugini
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John J Kelly
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nicole B Cherng
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Division of Minimally Invasive Surgery, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
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Fyhn TJ, Kvello M, Edwin B, Schistad O, Pripp AH, Emblem R, Knatten CK, Bjørnland K. Outcome a decade after laparoscopic and open Nissen fundoplication in children: results from a randomized controlled trial. Surg Endosc 2023; 37:189-199. [PMID: 35915187 PMCID: PMC9839805 DOI: 10.1007/s00464-022-09458-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/08/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Randomized controlled trials (RCT) comparing long-term outcome after laparoscopic (LF) and open fundoplication (OF) in children are lacking. Here we report recurrence rates and time to recurrence, frequency of re-interventions, use of antisecretory drugs, gastrointestinal symptoms, and patient/parental satisfaction a decade after children were randomized to LF or OF. METHODS Cross-sectional long-term follow-up study of a two-center RCT that included patients during 2003-2009. Patients/parents were interviewed and medical charts reviewed for any events that might be related to the fundoplication. If suspicion of recurrence, further diagnostics were performed. Informed consent and ethical approval were obtained. CLINICALTRIALS gov: NCT01551134. RESULTS Eighty-eight children, 56 (64%) boys, were randomized (LF 44, OF 44) at median 4.4 [interquartile range (IQR) 2.0-8.9] years. 46 (52%) had neurological impairment. Three were lost to follow-up before first scheduled control. Recurrence was significantly more frequent after LF (24/43, 56%) than after OF (13/42, 31%, p = 0.004). Median time to recurrence was 1.0 [IQR 0.3-2.2] and 5.1 [IQR 1.5-9.3] years after LF and OF, respectively. Eight (19%) underwent redo fundoplication after LF and three (7%) after OF (p = 0.094). Seventy patients/parents were interviewed median 11.9 [IQR 9.9-12.8] years postoperatively. Among these, use of anti-secretory drugs was significantly decreased from preoperatively after both LF (94% vs. 35%, p < 0.001) and OF (97% vs. 19%, p < 0.001). Regurgitation/vomiting were observed in 6% after LF and 3% after OF (p = 0.609), and heartburn in 14% after LF and 17% after OF (p = 1.000). Overall opinion of the surgical scars was good in both groups (LF: 95%, OF: 86%, p = 0.610). Patient/parental satisfaction with outcome was high, independent of surgical approach (LF: 81%, OF: 88%, p = 0.500). CONCLUSIONS The recurrence rate was higher and recurrence occurred earlier after LF than after OF. Patient/parental satisfaction with outcome after both LF and OF was equally high.
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Affiliation(s)
- Thomas J. Fyhn
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, 4950, Nydalen, Oslo, 0424 Norway
| | - Morten Kvello
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, 4950, Nydalen, Oslo, 0424 Norway
| | - Bjørn Edwin
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485The Intervention Centre, Oslo University Hospital, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Hepatopancreatobiliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Ole Schistad
- grid.55325.340000 0004 0389 8485Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, 4950, Nydalen, Oslo, 0424 Norway
| | - Are H. Pripp
- grid.55325.340000 0004 0389 8485Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Ragnhild Emblem
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, 4950, Nydalen, Oslo, 0424 Norway
| | - Charlotte K. Knatten
- grid.55325.340000 0004 0389 8485Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Kristin Bjørnland
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, 4950, Nydalen, Oslo, 0424 Norway
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Gkolfakis P, Lorenzo D, Blero D, Louis H, Lemmers A, Arvanitakis M, Eisendrath P, Devière J. Pneumatic dilation for the treatment of persistent post-laparoscopic fundoplication dysphagia: long-term efficacy and safety. Expert Rev Gastroenterol Hepatol 2022; 16:289-296. [PMID: 35235494 DOI: 10.1080/17474124.2022.2049241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Post-laparoscopic fundoplication (LF) dysphagia occurs in 5%-17% of patients and optimal management remains a topic of expert discussion. We assessed the efficacy and safety of pneumatic dilation (PD) in patients with persistent post-lLF dysphagia. METHODS Medical files of patients treated with PD for persistent post-fundoplication-associated dysphagia were reviewed. The primary outcome was long-term clinical success. Secondary endpoints were initial clinical success, dysphagia recurrence rate, and PD-related complication incidence. RESULTS Overall, 46 patients (74% women, 57.9±11.9 years) underwent 74 PD (mean: 1.6±0.8). A 30 mm, 35 mm, and 40 mm balloon was used in 45.9%, 43.2%, and 10.8%, respectively, of dilations. Among 45 patients with available follow-up, the overall long-term success rate of PD was 31/45 (68.9% [55.4-82.4]). Initial clinical success was 36/45 (80% [68.3-91.7]). Dysphagia recurred in 9 patients (25%; 95%CI 10.9-39.1) and 4 of these were effectively treated with a new dilation. Among 14 non-responders to PD, 11 underwent surgery. Four complications (2 perforations, 1 muscularis dilaceration, and 1 peri-procedural bleeding) occurred in 4 patients (incidence: 5.4% [95%CI; 0.3-10.6]) and were treated with partially covered self-expandable esophageal stents andhemostatic clips. CONCLUSIONS Pneumatic balloon dilation for post-fundoplication-associated symptoms is associated with a satisfactory long-term success rate and acceptable safety profile.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Diane Lorenzo
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Hubert Louis
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devière
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up. Surg Endosc 2022; 36:5627-5634. [PMID: 35076737 PMCID: PMC9283162 DOI: 10.1007/s00464-021-08969-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 12/17/2021] [Indexed: 11/27/2022]
Abstract
Aims Numerous reports have addressed the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). Long-term follow-up after direct comparison of these two minimally invasive approaches is scarce. The aim of the present study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomized ROLAF trial. Methods In the ROLAF trial 40 patients with GERD were randomized to RALF (n = 20) or CLF (n = 20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score. Results The GSRS score was similar for RALF (n = 15) and CLF (n = 15) at 12 years´ follow-up (2.1 ± 0.7 vs. 2.2 ± 1.3, p = 0.740). There was no difference in QOLRAD score (RALF 6.4 ± 1.2; CLF 6.4 ± 1.5, p = 0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF [46% (6/13) vs. 33% (4/12), p = 0.806]. Conclusion In accordance with previous short-term outcome studies, the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term. Registration number: DRKS00014690 (https://www.drks.de).
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Yang X, Tan J, Liu Y, Feng Y, Shi R. Comparison of 180° anti-reflux mucosectomy versus 270° anti-reflux mucosectomy for treatment of refractory gastroesophageal reflux disease: a retrospective study. Surg Endosc 2021; 36:5002-5010. [PMID: 34782965 PMCID: PMC9160125 DOI: 10.1007/s00464-021-08857-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anti-reflux mucosectomy (ARMS) is a novel endoscopic treatment for refractory gastroesophageal reflux disease (rGERD). Several studies have validated its safety and effectiveness, but postoperative dysphagia remains in concern. Since the influence of different resection ranges on efficacy and complications of ARMS has rarely been studied, this study aimed to compare outcomes of 180°ARMS and 270°ARMS in treatment of rGERD. METHODS This study was conducted from August 2017 to September 2020. 39 eligible patients underwent either 180° ARMS or 270° ARMS and followed up at 6 months postoperation. Primary outcome measure was assessed by Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Secondary outcomes included quality of life, PPI use, gastroesophageal flap valve grade, presence of reflux esophagitis, acid exposure time (AET), distal contractile integral (DCI), and integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) and complication rate. Per-protocol analysis was performed. RESULTS Among 39 patients, 18 underwent 180° ARMS, while 21 underwent 270° ARMS. At postoperative 6 months follow-up period, primary outcome showed no significant difference between two groups (p = 0.34). Similarly, no significant difference was demonstrated between groups regarding most secondary outcomes except for fewer complaints of newly dysphagia in 180° ARMS group. No other serious complications were observed in both groups. CONCLUSION Although 180° ARMS and 270° ARMS could be equally effective for treatment of rGERD, 180° ARMS might be more recommended due to lower incidence of newly post-procedural dysphagia.
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Affiliation(s)
- Xinyi Yang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Dingjiaqiao street-87, Nanjing, 210009, Jiangsu, China
| | - Jiacheng Tan
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Dingjiaqiao street-87, Nanjing, 210009, Jiangsu, China
| | - Yang Liu
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Dingjiaqiao street-87, Nanjing, 210009, Jiangsu, China
| | - Yadong Feng
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Dingjiaqiao street-87, Nanjing, 210009, Jiangsu, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Dingjiaqiao street-87, Nanjing, 210009, Jiangsu, China.
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Rodríguez de Santiago E, Albéniz E, Estremera-Arevalo F, Teruel Sanchez-Vegazo C, Lorenzo-Zúñiga V. Endoscopic anti-reflux therapy for gastroesophageal reflux disease. World J Gastroenterol 2021; 27:6601-6614. [PMID: 34754155 PMCID: PMC8554403 DOI: 10.3748/wjg.v27.i39.6601] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/01/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease has an increasing incidence and prevalence worldwide. A significant proportion of patients have a suboptimal response to proton pump inhibitors or are unwilling to take lifelong medication due to concerns about long-term adverse effects. Endoscopic anti-reflux therapies offer a minimally invasive option for patients unwilling to undergo surgical treatment or take lifelong medication. The best candidates are those with a good response to proton pump inhibitors and without a significant sliding hiatal hernia. Transoral incisionless fundoplication and nonablative radiofrequency are the techniques with the largest body of evidence and that have been tested in several randomized clinical trials. Band-assisted ligation techniques, anti-reflux mucosectomy, anti-reflux mucosal ablation, and new plication devices have yielded promising results in recent noncontrolled studies. Nonetheless, the role of endoscopic procedures remains controversial due to limited long-term and comparative data, and no consensus exists in current clinical guidelines. This review provides an updated summary focused on the patient selection, technical details, clinical success, and safety of current and future endoscopic anti-reflux techniques.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid 28034, Spain
| | - Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra. Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center. Pamplona, Spain
| | - Fermin Estremera-Arevalo
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra. Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center. Pamplona, Spain
| | - Carlos Teruel Sanchez-Vegazo
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid 28034, Spain
| | - Vicente Lorenzo-Zúñiga
- Endoscopy Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia 46026, Spain
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Zerbib F, Bredenoord AJ, Fass R, Kahrilas PJ, Roman S, Savarino E, Sifrim D, Vaezi M, Yadlapati R, Gyawali CP. ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro-esophageal reflux disease. Neurogastroenterol Motil 2021; 33:e14075. [PMID: 33368919 DOI: 10.1111/nmo.14075] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/11/2020] [Accepted: 12/13/2020] [Indexed: 02/08/2023]
Abstract
Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term "refractory GERD" has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term "refractory GERD symptoms" only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.
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Affiliation(s)
- Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | | | - Ronnie Fass
- Digestive Health Center, MetroHealth System, Cleveland, OH, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Sabine Roman
- Hospices Civils de Lyon, Hôpital E Herriot, Digestive Physiology, Université de Lyon, Inserm U1032, LabTAU, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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10
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Olmi S, Cesana G, D'Angiolella L, Bonaldi M, Uccelli M, Mantovani L. Sleeve gastrectomy with tailored 360° fundoplication according to Rossetti in patients affected by obesity and gastroesophageal reflux: a prospective observational study. Surg Obes Relat Dis 2021; 17:1057-1065. [PMID: 33622604 DOI: 10.1016/j.soard.2021.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure. Recent studies demonstrated the correlation between LSG and gastroesophageal reflux disease (GERD). OBJECTIVES To evaluate the effectiveness of LSG + Rossetti antireflux fundoplication in patients affected by morbid obesity and GERD. SETTING High-volume bariatric center, Italy. METHODS This is a prospective, observational cohort study that enrolled 58 patients affected by obesity and GERD who underwent surgery. All the patients had a 12-month follow-up. Gastroscopies were performed preoperatively and at month 12 for 35 patients. RESULTS At 1 year after surgery, patients had a consistent decrease in body mass index, from 41.9 ± 4.6 kg/m2 to 28.2 ± 3.7 kg/m2. GERD improved in 97.1% of patients. Co-morbidities, such as hypertension, type 2 diabetes, respiratory dysfunction, and arthropathies improved as well. The visual analogue scale score regarding the global state of health increased significantly, from 58.1 ± 17.1% before surgery to 98.8 ± 4.1% at 1 year after surgery. Two patients had a fundoplication perforation and needed reparative surgery (3.5%). One patient had anemia that needed a blood transfusion (1.7%). Complications were reduced with a learning curve. CONCLUSION LSG + Rossetti fundoplication was shown to be a safe and effective intervention. It could be considered an option in obese patients affected by GERD. A longer follow-up is needed to establish the long-term outcomes.
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Affiliation(s)
- Stefano Olmi
- Department of Surgery, S.I.C.OB. (Italian Society of Bariatric Surgery) Referral Center for Bariatric Surgery, Policlinico San Marco, GSD University and Research, Bergamo, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Giovanni Cesana
- Department of Surgery, S.I.C.OB. (Italian Society of Bariatric Surgery) Referral Center for Bariatric Surgery, Policlinico San Marco, GSD University and Research, Bergamo, Italy; University of Milan, Milano, Italy.
| | - Lucia D'Angiolella
- Research Centre on Public Health (CESP) of the University of Milan-Bicocca, Monza, Italy
| | - Marta Bonaldi
- Department of Surgery, S.I.C.OB. (Italian Society of Bariatric Surgery) Referral Center for Bariatric Surgery, Policlinico San Marco, GSD University and Research, Bergamo, Italy; University of Milan, Milano, Italy
| | - Matteo Uccelli
- Department of Surgery, S.I.C.OB. (Italian Society of Bariatric Surgery) Referral Center for Bariatric Surgery, Policlinico San Marco, GSD University and Research, Bergamo, Italy
| | - Lorenzo Mantovani
- Research Centre on Public Health (CESP) of the University of Milan-Bicocca, Monza, Italy
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11
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New treatment method for refractory gastroesophageal reflux disease (GERD): C-BLART (clip band ligation anti-reflux therapy)-a short-term study. Surg Endosc 2020; 34:4516-4524. [PMID: 31728750 DOI: 10.1007/s00464-019-07238-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 10/28/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVES C-BLART (clip band ligation anti-reflux therapy) has been reported as a new alternative endoscopic treatment for refractory gastroesophageal reflux disease (GERD). This study evaluated the short-term efficacy of C-BLART for controlling GERD symptoms, esophageal acid exposure, esophagitis, and quality of life. METHODS Patients with refractory GERD were recruited for a nonrandomized concurrent comparison, with 60 patients in the C-BLART with tailored PPI use group and 43 patients in the BID proton pump inhibitor (PPI) group. The primary outcomes were esophageal acid exposure and the lower esophageal sphincter (LES) pressure. The GERD-Q score, esophagitis grade, and adherence degree were also recorded. Crossover from the BID PPI group to the C-BLART with tailored PPI use group was allowed after 6 months. RESULTS The LES pressure and GERD-Q score improved more in the C-BLART with tailored PPI use group (P < 0.001) after 6 months, with no significant difference in the decrease in esophagitis compared with the baseline endoscopic results (P = 0.268). Treatment with PPIs had been halted in 43% of the patients at 6 months after C-BLART. At 12 months after C-BLART, the DeMeester score showed a significant improvement compared with the baseline measurements (P = 0.025). The GERD-Q score and LES pressure did not significantly improve compared with the baseline values (P = 0.102, P = 0.184) in C-BLART with tailored PPI use group. At 6 to 12 months, n = 6 (10%) patients had undergone laparoscopic fundoplication to control their symptoms in all the patients after C-BLART. CONCLUSION C-BLART is a novel treatment for controlling refractory GERD symptoms, esophageal acid exposure, and LES pressure according to this short-term analysis, safely performed endoscopically to create an anti-reflux barrier with ligated bands. Despite improvements in DeMeester score, LES pressure, and GERD-Q scores in the C-BLART with tailored PPI use group, many patients continue to demonstrate objective evidence of GERD.
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12
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Gerull WD, Cho D, Kuo I, Arefanian S, Kushner BS, Awad MM. Robotic Approach to Paraesophageal Hernia Repair Results in Low Long-Term Recurrence Rate and Beneficial Patient-Centered Outcomes. J Am Coll Surg 2020; 231:520-526. [PMID: 32758533 DOI: 10.1016/j.jamcollsurg.2020.07.754] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known regarding important long-term outcomes after robotic paraesophageal hernia (PEH) repairs, such as symptom relief and recurrence rates. The aim of this study was to evaluate the long-term clinical outcomes in a large series of patients undergoing robotic PEH repair. STUDY DESIGN This prospective, IRB-approved study analyzed adult patients who underwent robotic PEH repair, from 2010 to 2014, at a high-volume tertiary academic medical center. Detailed information on patient characteristics, perioperative factors, and long-term patient-reported outcomes for up to 5 years postoperatively were collected. Objective long-term outcomes included radiographic evidence of PEH recurrence at 1, 3, and 5 years postoperatively. RESULTS A total of 233 patients underwent robotic PEH repair during the study period-70% were primary, 30% were revisional. Seventy-eight percent of patients (181) had a type III PEH, 21% (49) had a type IV, and 1% (3) had a type II. At 5 years postoperatively, 62% of patients (145 of 233) were available for follow-up, with a radiographic recurrence rate of 9% (13 of 145). Additionally, there was a significant improvement in the GERD-HRQL score at 5 years postoperatively (preoperative: 25.6 ± 8.7, 5-year postoperative, 4.5 ± 1.7, p < 0.01, 95% CI 19.7 to 22.5). CONCLUSIONS This study represents one of the largest longitudinal robotic foregut surgical databases to date. Our results demonstrate that robotic PEH repair with an experienced surgical team is a safe and effective alternative to laparoscopic repair, with excellent long-term outcomes, including a very low recurrence rate.
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Affiliation(s)
- William D Gerull
- Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO.
| | | | - Iris Kuo
- Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO
| | | | - Bradley S Kushner
- Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO
| | - Michael M Awad
- Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO
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13
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Danilova DA, Bazaev AV, Gorbunova LI. [Current aspects of surgical treatment of gastro-esophageal reflux disease]. Khirurgiia (Mosk) 2020:89-94. [PMID: 32105262 DOI: 10.17116/hirurgia202002189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of gastric content into the esophagus, pharynx, respiratory tract and oral cavity. In recent years, there has been a significant increase of the incidence of this disease, that significantly aggravates quality of life of the population. The 'gold standard' for treating GERD is anti-secretory therapy with proton pump inhibitors (PPIs). However, up to 40% of patients are unresponsive to PPIs even after dose adjustment. Advantages and disadvantages of modern surgical approaches for this pathology are reviewed. Laparoscopic fundoplication including Nissen (360°), Toupet (270°) and Dor procedures (180°) is the most common anti-reflux operation. In addition, new alternative surgical options are also discussed. For example, these are minimally invasive methods such as LINX reflux control system, electrical stimulation of the lower esophageal sphincter and transoral incisionless fundoplication (TIF). These methods are less aggressive and have less side effects. A comparative assessment of modern methods of surgical treatment of GERD is made.
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Affiliation(s)
- D A Danilova
- Privolzhsky Research Medical University of the Ministry of Health of the Russia, Nizhniy Novgorod, Russia
| | - A V Bazaev
- Privolzhsky Research Medical University of the Ministry of Health of the Russia, Nizhniy Novgorod, Russia
| | - L I Gorbunova
- Privolzhsky Research Medical University of the Ministry of Health of the Russia, Nizhniy Novgorod, Russia
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14
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Spann MD, Harrison NJ, English WJ, Bolduc AR, Aher CV, Williams DB, Hawkins AT. Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass. Am Surg 2020. [DOI: 10.1177/000313482008600336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.
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Affiliation(s)
- Matthew D. Spann
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noah J. Harrison
- Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - Wayne J. English
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron R. Bolduc
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chetan V. Aher
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D. Brandon Williams
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T. Hawkins
- Department of Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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15
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Rouphael C, Shakya S, Arora Z, Gabbard S, Rice T, Lopez R, Raja S, Murthy S, Thota PN. Esophageal dysmotility and other preoperative factors associated with acid suppressive therapy after fundoplication. Scand J Gastroenterol 2020; 55:1-8. [PMID: 31852331 DOI: 10.1080/00365521.2019.1701068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and aims: Acid suppressive therapy (AST) is frequently used after fundoplication. Prior studies show that most patients requiring AST after fundoplication have normal esophageal acid exposure and therefore do not need AST. Our aim was to determine the indications for AST use following fundoplication and the associated factors.Methods: Retrospective analysis of patients who underwent fundoplication at our institution between 2006 and 2013 with pre and postoperative esophageal physiologic studies was performed. Demographic data, symptoms, and findings on high resolution manometry, esophageal pH monitoring and upper endoscopy were collected.Results: Three hundred and thirty-nine patients were included with a median follow up time of 12.8[2.6, 47.7] months. Mean age was 59.6 ± 13.3 years and 71.4% were women. Of those, 39.5% went on AST following fundoplication with a median time to AST use of 15.7[2.8, 36.1] months. The most common reason for AST use was heartburn. Only 29% of patients had objective evidence of acid reflux. Preoperative factors associated with AST use following fundoplication were male gender (HR1.6, p = 0.019), esophageal dysmotility (HR1.7, p = 0.004), proton pump inhibitor use (HR2.3, p < 0.001) and prior history of fundoplication (HR1.8, p = 0.006). In those with paraesophageal hernia repair with Collis gastroplasty (N = 182), esophageal dysmotility (HR1.7, p = 0.047) and NSAID use (HR1.9, p = 0.023) were associated with AST use postoperatively.Discussion: AST use is common after fundoplication. Male gender, preoperative esophageal dysmotility, proton pump inhibitor use and redo fundoplication were associated with AST use following fundoplication. In those undergoing combined Collis gastroplasty, preoperative NSAID use and esophageal dysmotility predicted AST use.
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Affiliation(s)
- Carol Rouphael
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Sampurna Shakya
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Zubin Arora
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Gabbard
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Rice
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sudish Murthy
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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16
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Holmberg D, Santoni G, Xie S, Lagergren J. Gastric bypass surgery in the treatment of gastro-oesophageal reflux symptoms. Aliment Pharmacol Ther 2019; 50:159-166. [PMID: 31165515 DOI: 10.1111/apt.15274] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/14/2019] [Accepted: 03/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastric bypass is considered an effective treatment of co-existing gastro-oesophageal reflux (GERD) and obesity. Previous studies have had small sample sizes, short follow-up or substantial loss to follow-up. AIM To assess the long-term risk of remaining/recurring reflux symptoms after gastric bypass. METHODS This was a nationwide cohort study of all adults with preoperative reflux who underwent gastric bypass in Sweden between 2006 and 2015, with complete follow-up through 2016. The outcome was remaining/recurring reflux symptoms, defined as use of proton pump inhibitors or histamine-2 receptor antagonists for >6 months after surgery. Cumulative incidence and risk factors of reflux were assessed with multivariable Poisson regression. RESULTS Among 2454 participants (81.7% female; mean age: 46.1 years, SD: 9.8 years), who were followed for median 4.6 years (interquartile range: 3.1-6.3 years), reflux recurred in 48.8% (95% confidence interval [95% CI], 46.8-51.0) of participants within 2 years of gastric bypass and remained stable up to 10 years after surgery (yearly change in incidence rate ratio [IRR] of 1.00; 95% CI, 0.99-1.02). Risk factors for recurring reflux were high preoperative dose of anti-reflux medication (IRR 1.77; 95% CI, 1.60-1.96 compared with low dose), older age (IRR 1.12; 95% CI 1.02-1.24 comparing age >50 with <40 years), female sex (IRR 1.28; 95% CI, 1.16-1.42) and comorbidity (IRR 1.26; 95% CI, 1.14-1.39 comparing Charlson Comorbidity Index ≥2 with 0). CONCLUSIONS Reflux symptoms decrease rapidly after gastric bypass, but around half of operated patients require continuous anti-reflux medication. The treatment efficacy of gastric bypass on reflux symptoms might have been overestimated.
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Affiliation(s)
- Dag Holmberg
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giola Santoni
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Shaohua Xie
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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17
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Armijo PR, Hennings D, Leon M, Pratap A, Wheeler A, Oleynikov D. Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility. J Gastrointest Surg 2019; 23:36-42. [PMID: 30288691 DOI: 10.1007/s11605-018-3968-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients. METHODS A single-institution prospective database was reviewed (2007-2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05. RESULTS Fifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0 ± 18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1-7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia. CONCLUSIONS A tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.
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Affiliation(s)
- Priscila R Armijo
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA
| | - Dietric Hennings
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA.,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Melissa Leon
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA
| | - Akshay Pratap
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA.,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Austin Wheeler
- College of Medicine, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Dmitry Oleynikov
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA. .,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
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18
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Mayor MA, Fernando HC. Endoluminal Approaches to Gastroesophageal Reflux Disease. Thorac Surg Clin 2018; 28:527-532. [DOI: 10.1016/j.thorsurg.2018.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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19
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Oor JE, Broeders JA, Roks DJ, Oors JM, Weusten BL, Bredenoord AJ, Hazebroek EJ. Reflux and Belching after Laparoscopic 270 degree Posterior Versus 180 degree Anterior Partial Fundoplication. J Gastrointest Surg 2018; 22:1852-1860. [PMID: 30030717 DOI: 10.1007/s11605-018-3874-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 07/03/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic 270 degree posterior, or Toupet (LTF), and 180 degree anterior partial fundoplication (LAF) ensure equal reflux control and reduce the risk of gas-related symptoms compared to 360 degree (Nissen) fundoplication. It is unclear which type of partial fundoplication is superior in preventing gas-related side-effects. The aim of this study was to determine differences in effect of LTF and LAF on reflux characteristics and belching patterns. METHODS Upper gastrointestinal endoscopy, esophageal manometry, and 24-h combined pH-impedance monitoring were performed before and 6 months after fundoplication (n = 10, LTF vs. n = 10, LAF). Observed changes after surgery (∆) were compared between the two procedures. RESULTS Symptomatic reflux control as well as the reduction in the mean number of acid (∆ - 58.5 vs. - 66.5; P = 0.912), liquid (∆ - 17.0 vs. - 43.5; P = 0.247), and mixed liquid gas reflux episodes (∆ - 38.0 vs. - 40.0; P = 0.579) were comparable following LTF and LAF. There were no differences in the mean number of weakly acidic reflux episodes after LTF and LAF (1.0 (0.8-4) vs. 1.0 (0-3), P = 0.436). The reduction in proximal (P = 1.000), mid-esophageal (P = 0.063), and distal reflux episodes (P = 0.315) was comparable. Both procedures equally reduced the number of gastric belches (P = 0.278) and supragastric belches (P = 0.123), with no significant reduction in the number of air swallows after either procedure (P = 0.278). CONCLUSION LTF and LAF provide similar reflux control, with a comparable effect on acidic, liquid, and gas reflux. Both procedures equally reduced the number of belches and supragastric belches. This study provides the physiological evidence for the published randomized trials reporting similar symptomatic outcome after both types of partial fundoplication.
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Affiliation(s)
- J E Oor
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
| | - J A Broeders
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - D J Roks
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - J M Oors
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - B L Weusten
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - E J Hazebroek
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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Jakubauskas M, Jotautas V, Poskus E, Mikalauskas S, Valeikaite-Tauginiene G, Strupas K, Poskus T. Fecal incontinence after transanal endoscopic microsurgery. Int J Colorectal Dis 2018; 33:467-472. [PMID: 29470728 DOI: 10.1007/s00384-018-2983-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence. METHODS Patients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more). RESULTS One hundred thirty-two patients were included in the study. Patients' median follow-up time was 96 (12-168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18-82) vs. 68 (50-89) years; p = 0.004), underwent longer operations (50 (10-140) vs. 60 (15-210) min; p = 0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p = 0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010-1.106; p = 0.016). CONCLUSIONS Fecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.
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Affiliation(s)
| | - Valdemaras Jotautas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Eligijus Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Saulius Mikalauskas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Gintare Valeikaite-Tauginiene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Kestutis Strupas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Tomas Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania.
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Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:302-318. [PMID: 28827081 DOI: 10.1053/j.gastro.2017.07.049] [Citation(s) in RCA: 162] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/29/2017] [Accepted: 07/31/2017] [Indexed: 02/06/2023]
Abstract
Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can also be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive and behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio.
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